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Feature

Role of emergency care staff


inmanaging acute stroke
Caroline Watkins and colleagues explain how
some of the latest research focuses on the
headposition of patients in the first 24 hours
Correspondence
clwatkins@uclan.ac.uk
Caroline Watkins is professor of
stroke and older peoples care
and director of research at the
school of health, and director
of the Lancashire clinical trials
unit, at the University of Central
Lancashire
Craig Anderson is professor of
stroke medicine and clinical
neuroscience medicine, at the
George Institute for Global Health,
University of Sydney, NSW
Denise Forshaw is a senior clinical
trials manager at the Lancashire
clinical trials unit
Liz Lightbody is senior research
fellow at the clinical practice
research unit
Both at the school of health,
University of Central Lancashire
Date submitted
August 26 2014
Date accepted
August 26 2014
Author guidelines
rcnpublishing.com/r/
en-author-guidelines

Abstract
In June, the University of Central Lancashire opened
its clinical trials unit, where staff will run complex
intervention trials in a range of care areas, including
stroke, musculoskeletal health, public health and
mental health. One of the first trials looks at how
hospital nursing policies in the first 24 hours after
patients have had stroke affect their subsequent
survival and disabilities. Known as HeadPoST,
the study will recruit 20,000 patients globally,
with the 6,000 UK research participants managed
by Lancashire. This article explores the role of
emergency nurses in supporting the research.
Keywords
Stroke, head position, randomised control trial
STROKE IS the third leading cause of death
and the single most important cause of severe
disability in adults worldwide. In the UK, more than
110,000 people experience acute stroke each year,
and the cost of illness is estimated at 8.3 billion
annually (Scarborough et al 2011). Furthermore, with
ever ageing populations, the global burden of stroke
is set to increase (Truelsen et al 2006).
While prevention is crucial in reducing the burden
of stroke, well organised and efficient acute care
strategies are important in reducing its effects on
individuals and families. Outcomes can be improved
if people have better access to stroke-specialist
consultation, and to processes of care that ensure
accurate diagnoses and appropriate delivery of
timedependent treatments. Performance standards
in the delivery of acute stroke care include:
Rapid responses to 999 calls when stroke is
suspected.

18 September 2014 | Volume 22 | Number 5

Urgent transfer of patients to hospitals that


provide specialised hyper-acute stroke services.
Use of brain imaging within one hour of arrival
for people in whom urgent treatment is indicated
and within 12 hours for everyone else.
Thrombolysis or other urgent interventions for
eligible patients.
Immediate patient access to a high quality stroke
unit care.
Stroke is a clinical emergency and, to maximise
patient recovery, access to treatment must not be
delayed and, in recent years, stroke services have
been re-organised to improve access to stroke unit
care. However, if these improvements are to lead to
fewer delays, front line staff, such as paramedics
and emergency nurses, must be able to recognise the
signs of stroke early and accurately, and to facilitate
appropriate care.
In the care of people with stroke, time is brain.
In practice, this means that the goal of acute
stroke management is to stabilise patients and
complete initial assessments, including imaging
and laboratory studies, within 60 minutes of a
patients arrival at an emergency department (ED).
Practitioners need knowledge and skills to assess
patients suitability for thrombolysis and, if they
are to, request immediate brain scans and refer the
patients directly to stroke services.
Acute stroke management can involve, but is
not limited to, reperfusion therapies with clotbusting drugs and neurointerventions involving the
use of devices to retrieve clots that are occluding
large intracerebral vessels. While it is accepted
that stroke unit care can improve patients chances
of surviving without major disabilities (Stroke
Unit Trialist Collaboration 2013), the mechanisms
that produce beneficial effects are not precisely
EMERGENCY NURSE

Science Photo Library

understood. Acute stroke units may be effective


because their staff make standardised assessments,
follow early management protocols, and carry
out appropriate investigations, treatments and
individualised patient care.
Physiological monitoring is considered an important
component of individualised acute stroke care
even though evidence of the benefits of monitoring
is unclear (Jones et al 2007). However, there is a
need for nurse-initiated, evidence-based protocols
for the management of fever, hyperglycaemia and
swallowing dysfunction (Middleton et al 2011),
while early control of elevated blood pressure has
been shown to improve recovery from intracerebral
haemorrhage (Anderson et al 2013).

Study
There is evidence that, if patients with large-vessel
ischaemic stroke are in the head-down, flat
position, their cerebral blood flow improves
(Olavarra et al 2014). However, the head-up position
may be preferable in patients with a large amount
of oedema following intracerebral haemorrhage or
ischaemic stroke related to proximal occlusion of
the middle cerebral artery.
The head position in acute stroke trial (HeadPoST),
an international cluster, cross-over, randomised
control trial funded by the National Health and
Medical Research Council of Australia, will determine
the best head position for patients with acute stroke.
Researchers will compare outcomes among
patients who are nursed while lying flat with those
among patients who are nursed while sitting up
during the first 24 hours after they are admitted.
HeadPoST is the largest trial of a stroke nursing
intervention and will be co-ordinated in the UK by
the Lancashire clinical trials unit.
The trial has a pragmatic design to allow the
inclusion of consecutively admitted patients with
acute stroke who can be nursed in one of two head
positions as part of their usual care. The head
positions are lying flat and sitting up, and each is
determined by random allocation. After 70 patients
have been nursed in one position, hospital staff will
cross over to nursing the next 70 patients in the
other position.
A cluster design has been chosen to reduce
the potential for contamination between groups,
promote consistent nursing care and facilitate
conduct of the study across an estimated
140 hospitals, including 40 in the UK.
Patients are put into the allocated head position
as soon as possible after they present to EDs to
ensure that the effects of head position can be
assessed while there is the greatest potential for
EMERGENCY NURSE

Computed tomography scan of a patients brain after stroke

benefit or harm. Nurses are responsible for the


positioning and monitoring of patients, so they must
ensure this intervention is carried out.
Almost all stroke care pathways require patients
to pass through EDs, where staff are essential to
early diagnosis, assessment, treatment and patient
management. As new therapeutic treatments for
stroke emerge, the role of ED staff in stroke care
may become increasingly important. Meanwhile,
ED staff remain crucial patient advocates who can
ensure the content, sequence and timing of stroke
care produce the best outcomes for patients.

Find out more


Details of the Lancashire clinical trials unit are
available at tinyurl.com/lwdjn6o
References
Anderson CS, Heeley E, Huang Y et al (2013) Rapid blood pressure lowering
in acute intracerebral hemorrhage. New England Journal of Medicine.
368, 25, 2355-2265.
Jones SP, Leathley MJ, McAdam JJ (2007) Physiological monitoring in acute
stroke: a literature review. Journal of Advanced Nursing. 60, 6, 577-594.
Middleton S, McElduff P, Ward J et al (2011) Implementation of evidencebased treatment protocols to manage fever, hyperglycaemia, and swallowing
dysfunction in acute stroke (QASC): a cluster randomised controlled trial.
The Lancet. 378, 9804, 1699-1706.
Olavarra VV, Arima H, Anderson CS et al (2014) Head position and cerebral
blood flow velocity in acute ischemic stroke: a systematic review and metaanalysis. Cerebrovascular Diseases. 37, 6, 401-408.
Scarborough P, Morgan RD, Webster P (2011) Differences in coronary heart
disease, stroke and cancer mortality rates between England, Wales, Scotland
and Northern Ireland: the role of diet and nutrition. BMJ Open. 1, 1.
Stroke Unit Trialists Collaboration (2013) Organised inpatient (stroke unit)
care for stroke. Cochrane Database of Systematic Reviews. 11, 9.
Truelsen T, Piechowski-Jozwiak B, Bonita R (2006) Stroke incidence
and prevalence in Europe: a review of available data. European Journal of
Neurology. 13, 6, 581-598.

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Conflict of interest
None declared

September 2014 | Volume 22 | Number 5 19

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